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r <br /> 21 <br /> Category Personal Care Plan Healthsource Plan <br /> Surgery <br /> Second Surgical Fully covered if authorized $20 copayment <br /> Opinion <br /> Medically necessary <br /> Transplants with Fully covered Fully covered <br /> prior authorization (proposed 1/1/96) <br /> Heart, Kidney, Liver <br /> Cornea, Bone Marrow <br /> Prescription <br /> Services <br /> Prescription charges $5 generic, $10 brand name $3 generic, $10 brand name <br /> (proposed 1/1/96) <br /> 34 day supply or 100 unit doses 34 day supply <br /> whichever is greater <br /> Fertility Drugs Covered drug if authorized Not covered <br /> by physician <br /> Short Term <br /> Rehabilitation& <br /> Physical Therapy Fully covered for 30 visits per year $20 copayment <br /> for each type of therapy 20 visits per year <br /> Mental Health <br /> Outpatient 1 -20 visits $20 copayment 1 -20 visit$20 copayment <br /> 21- 30 visits $30 copayment <br /> 1-20 group visits $10 copayment <br /> 21- 30 group visits $15 copayment <br /> (proposed 1/1/96) <br /> Inpatient $100 copayment per day 20%copayment <br /> 30 day limit <br /> (proposed 1/1/96) <br /> Mental Health No maximum $7,500 per year <br /> Lifetime Maximum $15,000 lifetime <br />